2522 Week 10 Outline... • Acute Assessment & Interventions • Stable Assessment & Rehabilitation STROKE ...AKA ‘BRAIN ATTACK’ Death of brain tissue due to a disturbance in blood supply to the brain. Ischemic: loss of blood flow Hemorrhagic: bleeding into the brain or onto the surface of the brain Result: brain tissue damage and neurological deficits Prevention is key!!! Prevention = Health Promotion = Education via Community & Public Health Risk Factors Non-modifiable • Age • Gender • Ethnicity and race • Heredity/family history • Low birth weight Modifiable • Hypertension • Metabolic syndrome • Heart disease • Heavy alcohol consumption • Oral contraceptive use • Physical inactivity • Smoking • Sleep apnea Pathophysiology Ischemic Stroke (80%) Thrombotic stroke Embolic stroke Hemorrhagic Stroke (15%) Subarachnoid hemorrhage Intracerebral hemorrhage ACUTE ASSESSMENT & INTERVENTION In depth assessment AFTER client receives treatment & is stable Motor Elimination Communication SpatialPerceptual Affect Intellectual Diagnosis… Preserve life Prevent further brain damage Reduce disability Diagnostic Studies When symptoms of a stroke occur, diagnostic studies are done to – confirm that it is a stroke. – identify the likely cause of the stroke. CT is the primary diagnostic test used after a stroke. 18 Assessment CT Scan 60 Minutes Initial Interventions… Airway – Patency Breathing – Pulse Ox & O2 – Monitor ventilation Circulation – IV access – BP High or low??? Disability (NEURO) – – – – Position head midline CT scan STAT HOB 30 degrees Seizure precautions Copyrights apply Cerebral Blood Flow Hyper & Hypotension CPP = MAP – ICP (+Autoregulation) Hypertension is common immediately after stroke. – Drugs to lower BP are used only if BP is markedly increased. Fluid and electrolyte balance must be controlled carefully. – Adequate hydration promotes perfusion and decreases further brain injury. 24 Acute Care - Interventions 1. Ensure patent airway. 2. Call stroke code or stroke team. 3. Remove dentures. 4. Perform pulse oximetry. 5. Maintain adequate oxygenation. 6. Obtain IV access with normal saline. 7. Maintain BP according to guidelines. 8. Remove clothing. 9. Insert Foley catheter 10.Obtain CT scan immediately. 11.Perform baseline laboratory tests. 12.Position head midline. 13.Elevate head of bed 30 degrees if no symptoms of shock or injury occur. 14.Institute seizure precautions. 15.Anticipate thrombolytic therapy for ischemic stroke. 16.Keep client NPO until swallow reflex evaluated . 25 Search for causes… Ongoing Interventions… • VS & neuro status • Recombinant tissue plasminogen activator (tPA) • Aspirin • Plavix • Anticoagulants • Surgery Recombinant tissue plasminogen activator (tPA) Inclusion Criteria • • Diagnosis of ischemic stroke causing disabling neurologic deficit in a patient who is 18 years of age or older. Time from last known well (onset of stroke symptoms) less than 4.5 hours before alteplase administration. Absolute Exclusion Criteria • Any source of active hemorrhage or any condition that could increase the risk of major hemorrhage after alteplase administration • Any hemorrhage on brain imaging Relative Exclusion Criteria • Historical • Clinical • CT or MRI Findings • Laboratory • Glucose = less than 2.7 mmol/L or greater than 22 mmol/L • Elevated activated partial-thromboplastin time (aPTT) • International Normalized Ratio greater than 1.7 • Platelet count below 100,000 per cubic millimetre Canadian Stroke Best Practices, 2018 28 Antiplatelet Therapy For clients not treated with TPA – Acetylsalicylic acid (ASA) – Clopidogrel Surgical Interventions for Stroke 1. Ischemic stroke • EVT 2. Hemorrhagic stroke • Immediate evacuation of aneurysm-induced hematomas • Cerebellar hematomas >3 cm 3. Aneurysms • Clipping or coiling 30 Acute Endovascular Thrombectomy Treatment (EVT) Figure 60-8 Endovascular treatment removes blood clots in clients who are experiencing ischemic strokes. The retriever is a long, thin wire that is threaded through a catheter into the femoral artery. The wire is pushed through the end of the catheter up to the carotid artery. The wire reshapes itself into tiny loops that latch onto the clot, and the clot can then be pulled out. To prevent the clot from breaking off, a balloon at the end of the catheter inflates to stop blood flow through the artery. Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 31 Clipping and Wrapping of Aneurysms Fig. 60-9. Clipping of aneurysms. GDC Coil Mr. Williams is a 63-year-old man who was admitted to hospital with manifestations of a stroke. WATCH: https://www.heartandstroke.ca/stroke/signs-ofstroke (0-1:19 minutes) Note your assessment findings while watching. Diagnostic Studies Cardiac assessment – Electrocardiogram – Chest x-ray – Cardiac markers i.e. Troponin – Echocardiography Blood glucose 35 Other Diagnostic Studies • • • • • • CTA MRI, MRA Cerebral or carotid angiography Digital subtraction angiography Transcranial Doppler ultrasonography Lumbar puncture 36 STABLE ASSESSMENT & INTERVENTION NURSING MANAGEMENT Assessment for STABLE client – HPI, meds, RF’s, FHx – Comprehensive neuro exam Planning – Goals • Maximize communication abilities. • Avoid complications of stroke. • Maintain effective personal and family coping. Implementation – Health promotion • Remember: prevention=promotion=teaching • Removal & reduction of risk factors, reinforce health behaviors • Ultimately the client’s choice! – Address & intervene regarding system issues identified – Ambulatory & home care • Rehabilitation Evaluation Assess goals - the client will: – maintain stable or improved level of consciousness. – attain maximum physical functioning. – maximize self-care abilities and skills. – maintain stable body functions. – maximize communication abilities. – avoid complications of stroke. – maintain effective personal and family coping 40 Rehabilitation when the client is stable • After stroke has stabilized for 12–72 hours, collaborative care shifts from preserving life to lessening disability and attaining optimal functioning. • Client may be transferred to a rehabilitation unit, outpatient therapy, or home care-based rehabilitation. Transfer of Care Ambulatory and home care – – – – – – – Ensure clear communication of client status Nutrition Mobility Exercises Hygiene Toileting Education provided • Self-care skills – Family/support system 42 Assessment When the client is stable, obtain description of the current illness with attention to initial symptoms. history of similar symptoms previously experienced. current medications. history of risk factors and other illnesses. family history of stroke or cardiovascular disease. 43 Comprehensive Neurological Exam • Level of consciousness Canadian Neurological Scale vs GCS • Cognition • Motor abilities • Cranial nerve function • Sensation • Proprioception • Cerebellar function • Deep tendon reflexes 44 Canadian Neurological Stroke Scale Notify MD STAT if: • a decrease of > 1 point and/or • changes noted in pupil size or reaction to light or • changes in vital signs 45 Nursing Documentation Retrieved from: https://www.strokenetworkseo.ca/sites/strokenetworkseo.ca/files/neuro_assessment_gzwart.pdf Ongoing Monitoring Respiratory and Neurological systems Respiratory system – Risk for atelectasis – Risk for aspiration pneumonia – Risks for airway obstruction – May require endotracheal intubation and mechanical ventilation Neurological system – Monitor closely to detect changes suggesting • extension of the stroke. • ↑ ICP. • Vasospasm. • recovery from stroke symptoms. 47 Ongoing Monitoring Cardiovascular system Cardiac efficiency may be compromised. • Monitoring vital signs frequently • Monitoring cardiac rhythms • Calculating intake and output, noting imbalances • Regulating IV infusions DVT risk due to immobility, loss of venous tone, and ↓ muscle pumping in leg 48 Motor Nutrition & Communication Elimination SpatialPerceptual Affect Intellectual Motor Function • Most obvious effect of stroke • Include impairment of – Mobility – Respiratory function – Swallowing and speech – Gag reflex – Self-care abilities 51 Ongoing Monitoring Musculo-skeletal system Goals are to maintain optimal function and prevent injury. – Prevent joint contractures and muscular atrophy – Range-of-motion exercises – Positioning *Paralyzed or weak side needs special attention when positioning and during transfers Positioning – Trochanter roll at hip to prevent external rotation – Hand splints to prevent hand contractures – Arm supports with slings and lap boards to prevent shoulder displacement – Avoidance of pulling the client by the arm to avoid shoulder displacement – Posterior leg splints, footboards, or high-topped tennis shoes to prevent foot drop – Hand splints to reduce spasticity 52 Communication Aphasia is the total loss of comprehension and use of language. VS Dysphagia refers to difficulty related to the comprehension or use of language and is due to partial disruption or los Dysarthria: disturbance in the muscular control of speech. Does not affect the meaning of communication or the comprehension of language, but it does affect the mechanics of speech. Impairments may involve •pronunciation •articulation •phonation Occurs when damage occurs to dominant hemisphere of the brain **Left hemisphere for RH and most LH 53 Dysphagia Four categories – Expressive – Receptive – Anomic/amnesic – Global A massive stroke may result in global aphasia, in which all communication and receptive function are lost. Ongoing Monitoring and Supports Communication Monitor for changes Speak slowly and calmly, using simple words or sentences. Gestures may be used to support verbal cues. 55 Affect May have difficulty controlling their emotions. Emotional responses may be exaggerated or unpredictable. Depression 56 Managing Atypical Emotional Responses • Distract the client. • Explain to family and client that emotional outbursts may occur. • Maintain a calm environment. • Avoid shaming or scolding client. 57 Memory and/or judgement may be impaired Intellectual Function **left-brain stroke is more likely to result in memory problems related to language. 58 Right sided stroke is more likely to cause problems in spatial–perceptual orientation. Spatial–Perceptual Alterations Four categories: 1. Anosognosia 2. Erroneous perception of self in space 3. Agnosia 4. Apraxia 59 Ongoing Monitoring Sensory–perceptual alterations • Blindness in same half of each visual field is a common problem after stroke. – Known as homonymous hemianopsia • Other visual problems may include – diplopia (double vision). – loss of the corneal reflex. – ptosis (drooping eyelid). 60 Homonymous Hemianopsia (Food on left side is not seen) Figure 60-12 Spatial and perceptual deficits in stroke. Perception of a client with homonymous hemianopsia shows that food on the left side is not seen and thus is ignored. 61 Nutrition Nutrition should be a priority assessment – NPO until swallowing assessment completed – May initially receive IV infusions to maintain fluid and electrolyte balance – Swallow screening within 24 hours of hospital arrival – May require nutritional support Interprofessional: – Dietician – Speech-language pathology – Occupational therapist – Nursing 62 Assistive Devices for Eating Figure 60-13 Assistive devices for eating. A, The curved fork fits over the hand. The rounded plate helps keep food on the plate. Special grips and swivel handles are helpful for some persons. B, Knives with rounded blades are rocked back and forth to cut food. The person does not need a fork in one hand and a knife in the other. C, Plate guards help keep food on the plate. D, Cup with special handle. 63 Elimination Most problems with urinary and bowel elimination occur initially and are temporary. • Urinary frequency, urgency or incontinence • Constipation • Implement a bowel management program for problems with – bowel control. – constipation. – incontinence. • High-fibre diet and adequate fluid intake 64 Ongoing Monitoring Gastrointestinal and Genitourinary systems Gastrointestinal system Prevention and monitoring for constipation • Stool softeners or fibre • Fluid intake • Physical activity Genitourinary system Managing incontinence • promote normal bladder function. *Avoid the use of in-dwelling urinary catheters 65 Ongoing Monitoring Integumentary system Increased risk of skin breakdown due to: • Loss of sensation • Decreased circulation • Immobility *Compounded by client age, poor nutrition, dehydration, edema, and incontinence NB to prevent and monitor for pressure ulcers 66 IPT An interprofessional and specialized approach: – Physicians – Nurses – occupational therapists – Physiotherapists – speech-language pathologists – social workers – Dieticians – Pharmacist – Discharge planner – Psychologist – Palliative – Spiritual care Ongoing Monitoring Psychosocial and Coping Affects family • Emotionally • Socially • Financially – Changing roles and responsibilities – ? Social work NB to provide client and family education 68 Psychosocial and Coping Nurse may assist the coping process • Support communication between the client and family. • Discuss lifestyle changes. • Discuss changing roles within the family. • Be an active listener. • Include family in goal planning and client care. • Support family conferences. Stroke support groups – family and client 69 Another Perspective… Thank You
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